Provider Demographics
NPI:1366676389
Name:BOWEN, PHAEDRA M (LMP)
Entity Type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:M
Last Name:BOWEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 N JEFFERSON LN STE 303
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-7104
Mailing Address - Country:US
Mailing Address - Phone:509-290-6406
Mailing Address - Fax:
Practice Address - Street 1:546 N JEFFERSON LN STE 303
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-7104
Practice Address - Country:US
Practice Address - Phone:509-290-6406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
WA60252069225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist